IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 27thday of June, 2022
Present: Sri. Manulal V.S. President
Sri. K.M. Anto, Member
C CNo. 164/2019 (filed on 10/10/2019)
Petitioner : (1) George Joseph,
Kollamparampil.
(2) Cicy Joseph,
W/o. George Joseph,
Thrikkodithanam,
Changanassery, Kottayam
Pin – 686 105.
(Adv. Sebastian James Palakunnel)
Vs.
Opposite Parties : (1) MeeraAnil (Area Manager)
Religare Health Insurance
Company Ltd. 3rd Floor,
Door No.55/686 D1 and D2m
Vallathottam White Tower,
SahodaranAyyappan Rd,
Panampilly Nagar, Kochi,
Pin – 682036.
(2) Binoy Alex,
-do-
(3) Kishor J.
-do-
(For Op1, 2 and 3 Adv. Benoy Jose Mathew)
(4) Manager,
Union Bank of India,
Thrikodithanam Branch,
Kunnumpuram.
Additional opposite party (5) Care Health Insurance Company,
(impleaded as per IA 117/21) (Religare Health Insurance)
5th floor, 19 Chawla House,
Nehru Place, New Delhi – 110019
O R D E R
Sri. Manulal V.S. President
Case of the complainant is as follows:
On 16-9-2018 the complainants had availed a healthinsurance policy vide policy no. 1175847 from the fifthopposite party as per the direction of the forth opposite party.
On 6-8-2019 the first complainant was suffered from the chestpain and went to the casualty department of the Chethippuzhahospital from there he was taken to the Puspagiri Hospital. Hewas undergone for angioplasty on the same day. Though theclaim was lodged with the fifth opposite party the same was not
honoured. As per the direction of the fifth opposite party thetreatment records from the Chithippuzha hospital was sent to theopposite party. But the claim as repudiated by the fifthopposite party on 29-6-2018.
Upon notice from this commission opposite parties 1 to 3appeared and filed joint version. Thought the notice was served tothe fourth opposite party they did not care to appear before thecommission or to file version. Hence fourth opposite party set exparty. Fifth opposite party was impleaded in party array videorder in IA 117 of 21 dated 6-11-2021. Notice was duly servedto the fifth opposite party. Fifth opposite party did not appearedbefore the commission.
Version of the opposite parties 1 to 3 as follows:
The complainants availed an insurance policy for a sumassured of Rs.3,00,000/- under the group insurance policyholdername Union Bank of India vide policy number 11758547 undera plan name ‘Group Care (Union HealthSureksha)’ covering theperiod from 16-9-2018 to 15-9-2019 and the samewas renewedfrom 16-9-2019 to 15-9-2020.The insurance coverage is Group Insurance Coverage for theaccount holders of Union Bank of India. The complainant hasfiled a proposal form through the Thrikkodithanam Branch ofthe Union Bank Of India. In the proposal form the complainantis required to fill up three columns regarding health and life styleinformation. In the third column in health and lifestyleinformation was that “does the insured member use gutka,tobacco, pan masala or any recreational drugs or consume morethan 5 cigarettes and / 4 units of alchohol per day ( 1 unit wouldbe 30ml of liquor) and the answer given bythe petitioner was‘No”.
The first complainant was brought to the emergency departmentof St.Thomas hospital Chithippuzha, with the complaint of acuteRtrosternal Chest pain radiating to inter scapular regions. Sincethe bystanders wanted to shift the petitioner to PuspagiriHospital, he was discharged against the medical advice. Therewas a request for the cashless hospitalization for medicalinsurance policy from Puspagigiry hospital and sincerequirement for cashless settlement were not furnished in timeand so the same was denied on 9-8-2019 and requested forsubmitting reimbursement claim with all supportive documents /treatments records.
Subsequently claim form dated 16-8-2019 was submitted by thecomplainant for settlement of the medical reimbursement. Theopposite party processed the file and requested for somedocuments on 26-8-2019. Since documents were not provided,a reminder was sent to the petitioner on 5-9-2019 and 15-9-2019. On perusal of initial assessment form from the Puspagirimedical collage dated 6-8-2019 it is found that doctor examinedcomplainant on 6-8-2019 and the doctor recorded the historyand it is further recorded that the petitioner smokes 20 cigarettesper day. Accordingly the opposite partiesrepudiated the claim on 29-9-2019 for the reason that non-disclosure of smoking history in the proposal form, clause 4.1of the terms and conditions of the policy and non-disclosure ofmaterial particulars or any material information having beenheld in the proposal form. The opposite party also took an expertopinion from Dr. C.H.Asrani in order to substantiate the fact the petitioner’s smoking is a known and accepted risk factor forpatient’s ailment. It is submitted in the version that at the timeof taking the policy complainant suppressed a material factfrom the proposal form and non-disclosure of these facts is aground for the repudiating the claim. Hence the complainant isnot entitled for any reliefs and the complaint is liable to bedismissed.
Complainant filed proof affidavit in lieu of chief examination andmarked exhibits A1 to A8. Sahilchauhan who is the Legal Manager of the fifth opposite party filed proof affidavit andmarked exhibit B1 to B16.
On evaluation of complaint version and evidence on record wewould like to consider the following points.
- Whether there is any deficiency in service on the part of theopposite parties?
- If so what are the reliefs?
For the sake and convenience we would like to consider thepoint number 1 and 2 together.
There is no dispute on the fact that complainants availed aninsurance policy for a sum assured of Rs.3,00,000/- under thegroup insurance policyholder name Union Bank of India vide policy number 11758547 under a plan name Group Care (UnionHealthSureksha) covering the period from 16-9-2018 to 15-9-2019. Exhibit A1 is the policy issued by the fifth opposite partyto the complainant. The specific case of the complainants is thatthe first complainant. He has suffered from acute chest pain on 6-9-2019 and he was treated in St. Thomas Hospital Chethipuzhaand from there he was shifted to Pushpagiri hospital on thesame day and treated there as inpatient. Exhibit A2 (e) provesthat the first complainant was treated as inpatient in Pushpagirihospital from 6-9-2019 to 10-9-2019 and angioplasty wasperformed. It is further proved by exhibit A2(d) that firstcomplainant had paid Rs.1,51,909 towards the expense for thetreatment in Pushpagiri hospital. Exhibit A2 is the bill issued for an amount of Rs.495, towards the treatment expenses atSt. Thomas hospital and exhibit A2 (a) is the bill issued fromthe St. Thomas hospital as transportation charge from St.Thomas hospital to Pushpagiri hospital. According to thecomplainant though the fifth opposite party offered cashlesstreatment facility the claim submitted by him was repudiated.
Complaint was resisted by the opposite parties 1 to 3 and thefifth opposite party that they repudiated the claim on the groundof suppression of material facts by the insured. It is submittedby the opposite parties 1 to 3 and fifth opposite parties that thedoctor who examined the complainant on 6-8-2019 recorded the history and it is further recorded that thepetitioner smokes 20 cigarettes per day. It is contended by theopposite parties that these facts were not disclosed by the firstcomplainant in the proposal form. On perusal of exhibit B5 it isproved that the complainant had specifically answered innegative to the queries regarding his habit of smoking and usingliquors etc. Exhibit B14 which is photocopy of the inpatientinitial assessment record from the Puspagiri Hospital we can seethat it was recorded as “smoker -20 cigarettes/day”. Oppositeparty relied on the clause. 3.2 of terms and conditions of thepolicy. As per clause 3.2( xxvii) Act of self-destruction or self-inflicted Injury, attempted suicide or suicide while sane orinsane or Illness or Injury attributable to consumption, use,misuse or abuse of tobacco, intoxicating drugs and alcohol areincluded in permanent exclusion from the coverage of thepolicy.
According to the opposite party the complainant had suppressedhis habit of smoking at the time filing the proposal form,which is material fact which would influence them whether toaccept the risk or not. Exhibit B16 which is an opinion from Dr. C.H. Asrani who is an empanel doctor of theoppositeparty insurance company. In Exhibit B16 it is stated that“Patients’scoronoary artery disease and subsequent ACS, IW,PWMI, CAG and PTCA he underwent are attributable to hissmoking”. However on perusal of B14 inpatient initial assessment record from the Puspagiri hospital we can see thatthere was no mention about the person who had made thedisclosure regarding the history of the illness and other details.
On perusal of Exhibit B14 we cannot arrive at conclusion thatthe whether the complainant was conscious or not at the time ofthe recording of history at Pushpagiri Hospital. More overExhibit B14 does not contain the signature and name of theperson who recorded the same. It does not contain the seal andsignature of any of the doctors or any other officials of thehospital. It is pertinent to note that the opposite parties did notfile affidavit or examined the person who had made entries inExhibit B14 to prove that the history of illness was voluntarily
disclosed by the complainant. Without a cogent evidence wecannot accept the contention of the opposite party that thecomplainant had voluntarily disclosed these facts to the doctors.
Except ExhibitiB14 the opposite party did not adduce anyevidence of the treating doctor to prove that the ailment wassuffered by the complainant can be attributed to the allegedsmoking habit. On the basis of these evidence we are of theopinion that the opposite party’s contention that thecomplainant had suppressed the material fact will not sustain.
Thus the repudiation of the genuine claim of the complainant isnot justified. Admittedly, the opposite party did not provide thecashless facility to the complainant. These act amounts todeficiency in service on the part of the opposite parties 1 to 3and 5. No doubt the deficient act of the opposite party causedmuch mental agony and hardship to the complainant for whichthe opposite partite 1 to 3 and 5 are jointly and severally labileto compensate.
In the light of above discussions we allow the complaint andpass the following order.
- We hereby direct the opposite parties 1 to 3 and 5 to payRs.1,53,859/-to the complainant which is the amount incurred byhim for the treatment expenses.
- We hereby direct the opposite parties 1to3 and 5 to pay Rs.25,000/- as compensation to the complainant .
- We hereby direct the opposite parties 1to3 and 5 to pay Rs.25,00/- to the complainant as cost of this litigation.
The opposite parties 1 to 3 and 5 are jointly and severally liableto pay the awarded amount within 30 days from the receipt ofthis order .In default the awarded amounts will carry 9% fromthe date of this order till realization.
Pronounced in the Open Commission on this the 27th day of June, 2022.
Sri. Manulal V.S. President Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of insurance policy No.11758547
A2 series – Copy of medical bills.
A3 – Copy of e-mail letter dtd.10-08-19
A4 – Copy of e-mail dtd.29-09-2020
A5 – Copy of e-mail dtd.01-10-2019
A6- Copy of e-mail
A7 –Copy of e-mail
A8 – Copy of e-mail
Exhibits marked from the side of opposite party
B1 – Copy of certificate of incorporation pursuant to change of name
B2 – Copy of certificate of insurance and premium acknowledgement
B3 – Copy of certificate of insurance and premium acknowledgement
B4 – Copy of insurance policy terms and conditions
B5 – Copy of proposal form (subject to objection)
B6- Copy of medical certificate dtd.09-08-19 (subject to objection)
B7 – Copy of letter dtd.07-08-19 by opposite party to Pushapagiri Hospital
(subject to objection)
B8 – Copy of letter dtd.08-08-19 by opposite party to Pushpagiri Hospital
(subject to objection)
B9 -Copy of letter dtd.09-08-19 by opposite party to Pushpagiri Hospital
B10 - Copy of claim form
B11- Copy of letter dtd.26-08-19 by opposite party to 1st complainant (subject to objection)
B12-Copy of letter dtd.05-09-19 by opposite party to 1st complainant
B13-Copy of letter dtd.15-09-19 by opposite party to 1st complainant
B14- Copy of inpatient initial assessment from Pushpagiri Hospital (subject to objection)
B15- Copy of letter dtd.29-09-19 by opposite party to 1st complainant
B16 – Report from Dr. C.H. Asrani(Subject to objection)
By Order
Assistant Registrar
